Scott W. Sharkey

Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States

Background—A clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction and triggered by psychological stress is emerging, with reports largely confined to Japan. Methods and Results—Over a 32-month period, 22 consecutive patients with this novel cardiomyopathy were prospectively identified within a community-based practice in the Minneapolis–St. Paul, Minn, area. All patients were women aged 32 to 89 years old (mean 65±13 years); 21 (96%) were ≥50 years of age. The syndrome is characterized by (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing by angiography; (3) systolic dysfunction (ejection fraction 29±9%), with abnormal wall motion of the mid and distal LV, ie, “apical ballooning”; and (4) profound psychological stress (eg, death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses) immediately preceding and triggering the cardiac events. A significant proportion of patients (37%) had hemodynamic compromise and required vasopressor agents and intra-aortic balloon counterpulsation. Each patient survived with normalized ejection fraction (63±6%; P<0.001) and rapid restoration to previous functional cardiovascular status within 6±3 days. In 95%, MRI identified diffusely distributed segmental wall-motion abnormalities that encompassed LV myocardium in multiple coronary arterial vascular territories. Conclusions—A reversible cardiomyopathy triggered by psychologically stressful events occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome. This condition is characterized by a distinctive form of systolic dysfunction that predominantly affects the distal LV chamber and a favorable outcome with appropriate medical therapy.

A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results— We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [≥80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. Conclusions— Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers

AIMSnTo determine the safety and efficacy of a pharmaco-invasive reperfusion strategy utilizing half-dose fibrinolysis combined with transfer for immediate percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients presenting to remote rural hospitals. Primary PCI is preferred for STEMI if performed in a timely manner. However, <20% of STEMI patients transferred for PCI in the USA have door-to-balloon times <2 h.nnnMETHODS AND RESULTSnProspective data from the Level 1 MI programme were analysed. All STEMI patients presenting to the Minneapolis Heart Institute or 31 referral hospitals received aspirin, clopidogrel, and unfractionated heparin (UFH) at the presenting hospital and those presenting to hospitals ≥60 miles away also received half-dose fibrinolytic with transfer for immediate PCI. From April 2003 through December 2009, we enrolled 2634 consecutive STEMI patients in the Level 1 MI database including 660 transferred from remote hospitals utilizing pharmaco-invasive therapy and 600 patients who presented directly to the PCI centre. There were no significant differences in 30-day mortality (5.5 vs. 5.6%; P= 0.94), stroke (1.1 vs. 1.3%; P= 0.66) or major bleeding (1.5 vs. 1.8%; P= 0.65), or re-infarction/ischaemia (1.2 vs. 2.5%; P= 0.088) in patients receiving a pharmaco-invasive strategy compared with patients presenting directly to the PCI centre, despite a significantly longer door-to-balloon time.nnnCONCLUSIONnWithin a regional STEMI system of care, half-dose fibrinolysis combined with immediate transfer for PCI may be a safe and effective option for STEMI patients with expected delays due to long-distance transfer.

Takotsubo (Stress) Cardiomyopathy

Whenever a new and previously unrecognized medical condition enters our consciousness, considerable confusion and uncertainly can ensue. If a patient is afflicted by such a disease state, the natural reaction is, “I have never heard of what I have,” triggering considerable personal and family anxiety. Such is the case with the condition we now call takotsubo cardiomyopathy, which has received considerable attention from the media and has been assigned a myriad of names in the literature.nnInitial recognition of takotsubo cardiomyopathy occurred in Japan in 1990, with the first report emerging from the United States in 1998. Thereafter, scientific interest in this condition has increased steadily and dramatically. For example, in 2000, only 2 publications were recorded, compared with nearly 300 in 2010 (Figure 1). Now, takotsubo is widely recognized, with reports from 6 continents and diverse countries, including France, Belgium, Mexico, Australia, Spain, South Korea, China, Brazil, Germany, Israel, South Africa, Turkey, and Iceland.nnnnFigure 1. nIncreasing number of takotsubo cardiomyopathy publications by year, 2000 to 2010.nnnn### The Acute IllnessnnTakotsubo cardiomyopathy starts abruptly and unpredictably, with symptoms of chest pain and, often, shortness of breath, usually triggered by an emotionally or physically stressful event, and with a predilection for women older than 50 years of age …

Clinical Profile of Patients With High-Risk Tako-Tsubo Cardiomyopathy.

Although tako-tsubo cardiomyopathy (TTC) is regarded as a reversible condition with favorable outcome, a malignant clinical course evolves in some subjects. In this single-institution experience, we describe the clinical profile of patients with adverse TTC outcome. A cohort of 249 consecutive patients with TTC was interrogated for those with acute unstable presentation during the first 24xa0hours. Forty-seven patients (19%) experienced early complicated clinical course with cardiac arrest in 9 (ventricular fibrillation, nxa0= 4, pulseless electrical activity, nxa0= 3, and asystole, nxa0= 2) or marked hypotension in 38 (systolic blood pressure ≤90xa0mm Hg requiring vasopressors and/or balloon pump). Of the 47 patients, Killip class III to IV heart failure was present in 30 (64%). Despite treatment, 8 patients (3%; all women) died inhospital due to respiratory failure, cardiogenic shock, or anoxic brain injury. All 8 inhospital deaths occurred among the 47 patients with unstable presentation, including 2 after cardiac arrest and 6 with marked hypotension. Post-TTC event mortality for a period of 4.7 ± 3.4xa0years significantly exceeded that in a matched general US population (standardized mortality ratio 1.4; 95% confidence interval 1.1 to 1.9; pxa0= 0.005) largely due to noncardiac co-morbidities. In conclusion, contrary to widespread perception, TTC is not an entirely benign and reversible condition. Among this large cohort, a high-risk subgroup was identified with cardiac arrest or hemodynamic instability, accounting for all hospital deaths. Hospital nonsurvivors had a variety of irreversible co-morbid conditions with the potential to compromise clinical status and adversely affect short-term survival. Long-term survival after hospital discharge was also reduced compared with the general population because of noncardiac co-morbidities.

Evidence That High Catecholamine Levels Produced by Pheochromocytoma May be Responsible for Tako-Tsubo Cardiomyopathy.

Tako-tsubo cardiomyopathy (TC) is a novel form of acute heart failure, characterized by regional left ventricular dysfunction without coronary artery obstruction, and usually triggered by a stressful event. Excessive circulating catecholamines have been implicated in the pathophysiology of this condition. This report documents the unusual occurrence of acute TC events in 2 male subjects of disparate ages, 16 and 66xa0years, for whom subsequent investigation in both led to the unexpected discovery of catecholamine-producing pheochromocytoma. Marked elevation of plasma catecholamines (epinephrine, norepinephrine, and dopamine) was present in both subjects and were remarkably similar to those previously reported in female patients with TC triggered by emotional stress. These observations show a common link between TC occurrence and elevated catecholamine levels in both male and female patients and, therefore, support the hypothesis that excessive levels of catecholamines may be involved in the pathophysiology of TC independent of age or gender.

Outcomes of Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients With Previous Coronary Bypass Surgery

OBJECTIVESnThis study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion.nnnBACKGROUNDnThe outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era.nnnMETHODSnData was extracted from a large, regional STEMI systems prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012.nnnRESULTSnPrevious CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; pxa0= 0.82) and 1-year (10.8% vs. 9.1%; pxa0= 0.36) mortality, but 5-year (24.9% vs. 14.2%; pxa0< 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, pxa0= 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; pxa0= 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; pxa0= 0.71).nnnCONCLUSIONSnPatients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

What Medicare Knows About the Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a recently recognized, yet incompletely understood form of acute heart failure. Efforts to characterize TTC have been hampered by its relatively low incidence. In this issue of JACC; Heart Failure, Murugiah etxa0al. [(1)][1] have examined the United States Medicare

New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction

Aims: Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion. Methods and results: From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17–2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as ‘STEMI equivalent’. Conclusion: Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.

How gold is the gold standard? How gold does it need to be?†

Remarkable progress has been made in the treatment of ST-elevation myocardial infarction (STEMI) over the last two decades. The key to this success has been rapid reperfusion, in particular primary percutaneous coronary intervention (PCI). Fundamental to this process is the recognition of electrocardiographic changes related to acute coronary occlusion [1]. Rokos et al. correlate the results of the ECG and angiographic core labs from 3,602 STEMI patients enrolled in the HORIZONS-AMI trial in an attempt to provide insights into ECG patterns of ‘‘acute coronary occlusion’’ [2]. The authors focus on six specific areas: (1) the frequency of ST segment elevation by lead according to infarct related artery, (2) the prevalence of reciprocal changes, (3) the prevalence of borderline STEMI, and the frequency of patients enrolled with (4) true posterior MI, (5) left main occlusion, and (6) left bundle branch block. This study confirms the performance of ‘‘sentinel’’ leads, V2/V3 for left anterior descending (LAD) occlusion, and III for right coronary artery/circumflex occlusion and the value of reciprocal changes when present. Not a single patient with a true posterior infarct was enrolled and patients with left main occlusion or left bundle branch block were much less frequent than expected.